Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381)

Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy (OPT) and/or Speech Pathology Services (OSP)- Initial and Extension Site Requests (CMS-381)

OMB: 0938-0273

IC ID: 7932

Documents and Forms

Document Name Document Type
Form CMS-381 Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381) Form and Instruction
CMS-381 REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAID PROGRAM TO PROVIDE OUTPATIENT PHYSICAL THERAPY (OPT) AND/OR SPEECH PATHOLOGY SERVICES (OSP)- INITIAL AND EXTENSION SITE REQUESTS Combined Form CMS-1856 and CMS-381 (Final).pdf Form and Instruction
Combined Form CMS-1856 and CMS-381 (Crosswalked).docx Tracked changes IC Document
Crosswalk for Reviewers.docx Crosswalk IC Document